A Network Touches the Hard-to-Reach

January-February 2018


Expanding Access to Mental Health Services through Telehealth

Amid increasing demand and the well-documented shortage of mental health professionals, Avera Health, based in Sioux Falls, South Dakota, is harnessing its telehealth network — Avera eCARE® — to help bridge gaps in behavioral health services. Solutions include a new eCARE Behavioral Health Services program and emerging applications for the AveraNow platform that makes video visits possible via a mobile device.

The National Institute of Mental Health in Bethesda, Maryland, reports:

  • Approximately 1 in 5 adults in the U.S. experiences mental illness in a given year1
  • Approximately 1 in 25 adults in the U.S. experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities2
  • Approximately 1 in 5 youths ages 13-18 experiences a severe mental disorder at some point during his or her life3

At the same time, according to a report from the National Council for Behavioral Health in Washington, D.C., the current workforce of approximately 45,580 psychiatrists would need to increase by 2,800 to meet current demands for psychiatric care. That is a 6.4 percent shortage.4 By 2025, based on estimates of retirement and new entries into the workforce, the projected unmet need will be 6,090 psychiatrists, or a deficit of 12 percent.

Avera serves a largely rural region that comprises 71,000 square miles in the eastern half of South Dakota, along with portions of Iowa, Nebraska, Minnesota and North Dakota. Some residents within that footprint are hours away from behavioral health counselors and, especially, psychiatrists.

Left untreated, mental health disorders can lead to individual and societal problems such as suicide, addiction, homelessness or the breakdown of families, not to mention the personal cost of interrupted education and career paths. The effects of mental health disorders also touch a patient's family and loved ones. Through medication and therapy, however, such conditions often can be managed successfully and improved. In many cases, treatment can help the patient recover.

Since its inception in 2004, Avera eCARE has served more than 1 million patients. The telehealth service grew in response to the challenges of providing quality care in rural and underserved areas, and the network has expanded from Avera's home base in southeastern South Dakota to reach 340 sites in 14 states. Avera eCARE's varied applications include ICU, emergency, pharmacy, specialty visits, senior care, correctional health, school health and, most recently, behavioral health.

Avera began using telehealth in 1993 to provide face-to-face, real-time visits during which physicians in numerous medical specialties, including psychiatry, converse with patients via secure video and sound technology. Avera has been a leader in behavioral health across the Upper Midwest for decades; the ministry's strong commitment to behavioral health stems from Avera's belief in being compassionate caregivers and its desire to care for the whole person — body, mind and spirit.

In 2006 — a time when many health systems were scaling back or eliminating mental health services — Avera invested in a state-of-the-art, 110-bed behavioral health center in Sioux Falls, with five specialized units for children, adolescents, adults and seniors. Since that time, the senior unit moved to remodeled space at the Avera Prince of Peace Retirement Community in Sioux Falls to make room for additional beds. The average daily census for the Avera Behavioral Health Center has grown from 59 in 2005 to 90 in 2017, and often all beds are full.

The Avera Behavioral Health Center is home to a 24-hour center that provides patients with face-to-face assessment and triage using evidence-based standard protocols. Unless they are injured or they have overdosed, people with a psychiatric emergency generally need attention and assessment rather than ED-level care. Someone who is highly depressed and suicidal can walk into Avera's center and be assessed on the spot for appropriate care, saving costs associated with an emergency room visit.

Staffed with master's-level social workers, counselors and psychiatric nurses, the center receives close to 10,000 formal referral calls from emergency departments and schools around the region, as well as from family members and patients who may be feeling seriously depressed, anxious or who are having suicidal thoughts.

The assessment center can be reached through both a local and a toll-free number, and it also performs unscheduled assessments for individuals on a walk-in basis. The goal is to identify the appropriate level of care and to furnish an easy access point to mental health services. If the person appears to need inpatient care, members of the center's staff contact the on-call psychiatrist and relay the assessment results. If the need can be handled on an outpatient basis, staff members connect that patient with a provider.

The assessment service takes a significant load off emergency departments in Sioux Falls and surrounding communities. Avera Behavioral Health data for FY2017 indicated that without the assessment service, the ED at Avera McKennan Hospital & University Health Center in Sioux Falls could have had an additional 9,000 incoming calls and 5,500 walk-ins.

An evolutionary process led Avera to recognize the behavioral health program's telehealth potential. Before the center was built, Avera's behavioral health inpatient program and assessment center were located at Avera McKennan. There, if the emergency department needed behavioral health intervention, it was easy for a member of the assessment center staff to walk down to the ED and assist.

In 2006, when the assessment center moved into a new building off of the main campus, a master's level counselor was placed on call 24/7 to provide behavioral health assistance for the emergency department.

Three years later, Avera launched eCARE Emergency, a telemedicine service in which remote sites are connected to emergency medicine specialists via secure, interactive video and sound technology. The emergency medicine specialists who staffed the telemedicine service — most of whom also served in the ED at Avera McKennan — commented that it would be helpful to have mental health assessment available for telemedicine consultations to determine the appropriate care setting for a patient and, if necessary, to find an open bed.

The eCARE Emergency hub in Sioux Falls is linked to rural emergency rooms, providing immediate consultations and transfer assistance via two-way, high-definition video. At first, the on-call behavioral health assessment counselor's job expanded to include requests from remote sites. However, there often was a delay while the counselor was called and he or she then traveled to the eCARE hub. Such a delay did not fit as well with the immediate, real-time expectation for eCARE Emergency, where sites push a red button on the wall and are connected within seconds.

At the same time, other facilities expressed interest in using the Avera assessment center. For example, a non-Avera hospital in Nebraska asked if Avera could provide behavioral health assessment services via video, because the hospital did not feel it could hire the staff to set up its own program.

Fast forward to 2017, when Avera eCARE got the opportunity to receive up to $100 million in contractual funding from the federal Indian Health Service to provide telemedicine services to approximately 130,000 American Indians in South Dakota, North Dakota, Nebraska and Iowa. Without telemedicine, many of these individuals must travel hundreds of miles for specialty care, or they forgo care altogether.

"It is challenging to provide specialty health care in rural areas, and this is especially true in Indian Country," said Mary L. Smith, IHS principal deputy director. "IHS has long been a leader in information technology and electronic health records, and IHS experience shows that telemedicine is an effective way to increase access to quality health care services in remote, hard-to-reach areas."

The program incorporates services from Avera eCARE, including eCARE Emergency and Virtual Clinic, which allows patients to see specialists in such areas as behavioral health, cardiology, nephrology, pain management, pediatric behavioral health, rheumatology, wound care, ear, nose and throat care and dermatology.

Behavioral health assessment, therapy and psychiatry services are large components of the IHS project. To fulfill the contract requirements as well as meet the growing number of requests for behavioral health assessments, Avera has launched the eCARE Behavioral Health Services assessment center, modeled after the behavioral health assessment center in Sioux Falls.

The new eCARE Behavioral Health Services assessment center is staffed by experienced psychiatry nurses and housed at the eCARE hub in Sioux Falls known as eHelm, named in recognition of the significant grant funding Avera eCARE has received through The Leona M. and Harry B. Helmsley Charitable Trust.

The assessment service is offered to all 149 eCARE Emergency sites and also to one site that has its own assessment center during day and evening hours but relies on eCARE Behavioral Health between 10 p.m. and 10 a.m.

Requests for behavioral health assessment typically originate in the local emergency department. Avera psychiatry nurses use an 11-page assessment that includes various tools such as the PHQ-9 depression questionnaire and the Columbia Suicide Severity Rating Scale (C-SSRS). The psychiatry nurses not only help assess the level of care that a patient needs, they also call up to six inpatient sites within the appropriate area to seek placement opportunities.

Nurses are an extension of the physician or advanced practice provider on site. A local physician may be able to give 10 to 15 minutes of time before he or she must move on to another patient, but that's usually not enough time to get the full story in a behavioral health case. The psychiatry nurses are trained in evidence-based assessment tools that bring a lot of information to the surface and help inform the best next step for the patient. Given such information, physicians will know if a patient should be held or admitted, or if the appropriate care can be handled on an outpatient basis.

Also in conjunction with the IHS grant, Avera is stepping up its eCARE Specialty Clinic services to provide telehealth therapy as well as psychiatry visits to manage medication.

The IHS contract includes an expansion of eCARE Emergency and Specialty Clinic visits to reservation hospitals and clinics. Currently, telehealth behavioral health therapy and psychiatric medication management are being offered only to the reservation communities. Demand for these services likely will lead Avera to consider expansion to other sites.

"This service is just becoming available on the reservations, and already we're seeing a lot of young people and teens who would otherwise be unable to get therapy and intervention at times of crisis. They truly want help but are unable to get a ride to travel the three hours where help is available," said Becky Jibben, director of Avera eCARE Behavioral Health Services. "There are multiple issues. For example, there are kids who experience trauma when a friend or family member has committed suicide. This can develop into issues such as anger, depression and feeling like there's no way out."

Avera eCARE Emergency often is associated with serious health events such as heart attack, stroke or traumatic injury, but behavioral health has proven to be a leading request, particularly for children and teens. To help meet the Indian Health Service needs, Avera eCARE is looking at school-based programs on reservations, with the goal of providing early intervention.

Avera is using another new technology, the AveraNow platform, to extend its reach through the employee assistance program. In 2015, Avera launched AveraNow as a retail mobile video visit with an Avera provider through a smartphone, tablet or laptop. These visits provide urgent care for minor illnesses such as colds, flu, fever, stomach ailments and sinus infections, for example. Goals of this direct-to-consumer platform are to improve access to care at an affordable cost, and ultimately to connect patients to an Avera provider for regular preventive visits.

"Through a grant project, we had worked with AveraNow for a weight-loss and health coaching function with good results and were further challenged to consider other programs that could be offered through this platform," said Maria Drey, mobile health manager for Avera eCARE. "We saw EAP as a natural fit."

Avera's employee assistance program contracts with about 150 employers, covering 80,000 lives in 32 states. Employees and their immediate family members receive a set number of free counseling visits per year. Counseling helps individuals work through problems such as grief and loss, conflict, major decisions or family issues.

In the past, Avera has subcontracted for counseling services at sites where there are no Avera counselors. The AveraNow platform presented the opportunity to use Avera providers, rather than contracted counselors, for those at a distance. It also provided another avenue for employees who felt uncomfortable about walking into a counseling office, perhaps for fear of seeing a familiar face.

In 2016, Avera began an initial pilot project and then soft-launched the service, limiting it to covered employees in South Dakota in order to test the concept within Avera's own environment. Employees call an 800 number and, upon having their coverage verified, a scheduler lets them know when they can see an Avera counselor in person where applicable, a contracted counselor nearby, or an Avera counselor via the AveraNow platform.

Whatever mode the employee chooses, a provider is identified and a visit is set up. An AveraNow visit is handled face-to-face on a smartphone or laptop. Research indicates face-to-face technology is just as effective as face-to-face conversations across a table or desk, and employees who have used the technology report being comfortable with it. Millennials especially have been inclined to use AveraNow technology.

An innovative, "in-house" use of AveraNow technology is for executive coaching and counseling to promote well-being and to prevent burnout among physicians and advanced practice providers. In 2017, the well-being program, known as LIGHT, received the Catholic Health Association's annual Achievement Citation.

The future holds exciting possibilities for telehealth in behavioral health, and Avera wants to stay nimble enough to capitalize on such opportunities. For example, Avera Health has received a three-year grant from the Health Resources and Services Administration Federal Office of Rural Health Policy for its substance abuse treatment telehealth network grant program.

The "Link the Treatment: Avera Rural Substance Abuse Project" will use telehealth to expand access to substance use disorder treatment to people ages 12 and older who have been identified as having a substance use disorder and living in the areas served by Avera Flandreau Hospital in Flandreau, South Dakota, and Avera St. Luke's Hospital in Aberdeen, South Dakota. The grant will fund substance use disorder screening; brief intervention and referral to treatment; individual, group and relapse prevention therapy; and medication-assisted treatment via telehealth.

Also, eCARE is working on agreements for physician bedside support with two hospitals that have inpatient behavioral health services but a shortage of on-site psychiatrists.

The best use of telehealth is for access. As a mission-based organization, Avera believes that behavioral health is a basic service that should be readily accessible for all those we serve. As telehealth technology and resources allow, we will continue to leverage the technology to extend access to quality care while at the same time help create solutions to issues of cost and workforce shortages.

STEVE LINDQUIST is assistant vice president for behavioral health at Avera McKennan Hospital & University Health Center in Sioux Falls, South Dakota. Previously he served as director of mental health for the State of South Dakota and CEO of the George S. Mickelson Center for the Neurosciences.

BRIAN ERICKSON is administrator for Avera eCARE Specialty Clinic and Behavioral Health Services in Sioux Falls, South Dakota.


  1. National Institute of Mental Health, "Any Mental Illness (AMI) among U.S. Adults," web page. www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-adults.shtml.
  2. National Institute of Mental Health, "Serious Mental Illness (SMI) among U.S. Adults," web page. www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-smi-among-us-adults.shtml.
  3. National Institute of Mental Health, "Any Disorder among Children," web page. www.nimh.nih.gov/health/statistics/prevalence/any-disorder-among-children.shtml.
  4. Aaron Levin, "Report Details National Shortage of Psychiatrists and Possible Solutions," Psychiatric News, http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.4b24.

A Network Touches The Hard-to-Reach

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